IHS IEE Representation Form_Jan 2022_508 Compliant.pdf
PDF 129 KB Posted
- Attached to
- AMENDMENT 003 - Four (4) Administrative Support Assistants - Santa Fe Indian Health Center
- Solicitation number
- 75H70726Q00035
About this file
This document is an Indian Economic Enterprise Representation Form issued by the Indian Health Service (IHS), Office of Management Services, Division of Acquisition Policy. The form serves as a self-certification template for offerors responding to Sources Sought Notices, Requests for Information (RFI), or solicitations under the Buy Indian Act authority.
The form requires offerors to certify whether they meet the definition of an "Indian Economic Enterprise" with Indian Ownership under 25 U.S.C. 47 and HHSAR 326.601. Offerors must maintain eligibility at three critical junctures: at the time of offer submission, at the time of contract award, and throughout the full contract performance period. Any loss of eligibility during these periods requires immediate written notification to the Contracting Officer. The form mandates that successful offerors register with the System of Award Management (SAM) and may be subject to protest regarding eligibility status. Contractors must provide the name of the Federally Recognized Tribal Entity, the name of the 51% owner of the Indian Economic Enterprise (IEE), business name, DUNS number, and signature of the authorized certifying official. False or misleading information constitutes a violation under 18 U.S.C. 1001, while false claims during contract performance are subject to penalties under 31 U.S.C. 3729-3731 and 18 U.S.C. 287.
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Text version
DEPARTMENT OF HEALTH & HUMAN SERVICES
Indian Health Service
Office of Management Services Division of Acquisition Policy (DAP)
5600 Fishers Lane Rockville, MD 20857
INDIAN HEALTH SERVICE
BUY INDIAN ACT
INDIAN ECONOMIC ENTERPRISE
REPRESENTATION FORM
SOLICITATION/SOURCES SOUGHT/RFI #: _________________________________________________
PROJECT TITLE: ________________________________________________________
DATE: ___________________________________________________________________
In accordance with 25 U.S.C. 47 the Buy Indian Act, the signature below constitutes self-certification that the Offeror meets the definition of an “Indian Economic Enterprise” (HHSAR 326.601) in response to this Sources Sought Notice, Request for Information (RFI) or Solicitation and resultant contract.
The enterprise must meet the definition of “Indian Economic Enterprise” throughout the following time periods:
(1) At the time an offer is made in response to this solicitation;
(2) At the time of contract award; and
(3) During the full term of the contract performance period. At any point during these periods, if the Contractor no longer meets the eligibility requirements, the contractor must provide immediate written notification to the Contracting Officer.
Individual Contracting Officers may require documentation of eligibility before awarding a set-aside or sole source contracts under the Buy Indian Act and awards may be subject to protest if the eligibility of the successful Offeror is in question. In addition to the self-certification requirements, successful Offerors must also be registered with the System of Award Management (SAM).
Any false or misleading information submitted by an enterprise when submitting an offer in consideration of an award set-aside under the authority of the Buy Indian Act is a violation of the law and punishable under 18 U.S.C. 1001.
False claims submitted as part of contract performance are subject to the penalties enumerated in 31 U.S.C. 3729 to 3731 and 18 U.S.C. 287.
REPRESENTATION
The Offeror represents as part of its offer that it does _____, does not _____ meet the definition of an “Indian Economic Enterprise” with “Indian Ownership” under the authority of the Buy Indian Act.
Name of the 51% owner of IEE Firm
Certifying Signature
Print Name
Name of Federally Recognized Tribal Entity
Business Name
DUNS Number
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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